Evidence Based Approaches to Addiction and Mental Illness Treatment for Adults

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1 Evidence Based Practice Continuum Guidelines The Division of Behavioral Health strongly encourages behavioral health providers in Alaska to implement evidence based practices and effective program models. Beginning in FY 06, the Request for Proposals (RFP) disseminated by DBH placed a stronger and more specific emphasis on funding projects that could demonstrate an evidence base. All program designs were reviewed in the context of the evolving scientific evidence of what works best. Practices considered for implementation are organized into three categories: evidence-based, emerging promising practices, and values-based practices. While the categories overlap, this framework suggests that the publicly funded behavioral health system has a somewhat different obligation to implement practices in each category. Resource limitations and the unique realities of Alaska may require compromises with the national models. Client admissions to behavioral health treatment programs are based on the use of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR 2/ICD-9), and relevant criteria as defined by the American Society of Addiction Medicine Client Placement Criteria 2R (ASAM PPC-2R), adolescent, adult, and Opioid maintenance therapy (www.asam.org). Programs must demonstrate that each individual is served with a continuum of care and that client placement decisions are made in a manner that represents the use of DSM-IV-TR 2/ICD-9 and ASAM PPC 2R at intake, movement through treatment and at discharge. Evidence Based Approaches to Addiction and Mental Illness Treatment for Adults Evidence-Based Practices are defined as interventions that have shown consistent scientific evidence of producing preferred client outcomes. The National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) offer the following evidence-based practices for substance use disorders. 1. Cognitive Behavioral Interventions This approach involves using awareness and skillbuilding activities with clients. 2. Community Reinforcement This approach involves connecting the client with other needed agencies and services in the community. 3. Motivational Enhancement Therapy This approach involves using motivational interviewing strategies and interventions that are based on a stages of change model Step Facilitation This is a structured, individualized approach for introducing clients to a 12-step program. This can result in better meeting attendance for a longer period of time. 5. Contingency Management This approach includes behavioral contracting where clients have opportunities to earn rewards for specific desirable behaviors. Data demonstrates that stimulant users respond well to this approach, stay in treatment longer, make measurable progress and have better treatment outcomes.

2 6. Pharmacological Therapies There is strong evidence that medication like Antabuse, Naltrexone, Methadone and Buprenorphine when used in conjunction with other therapies can help stabilize a person s life when their alcohol or drug use is out of control. 7. Systems treatment This term refers to treating clients in their natural social environment. Couples therapy, family therapy, and multi-systemic family therapy are all examples of systems treatment models. There is substantial evidence indicating that clients whose families are engaged in the treatment process show improved outcomes. Systems treatment appears to be especially effective with young people. 8. Integrated Dual Disorders Treatment This treatment approach helps people recover by offering mental health and substance abuse treatment services together, in one setting. The same clinicians (or team of clinicians) offer an individualized treatment plan, which addresses both the mental health and substance abuse problems. A wide range of services is offered in a stage-wise fashion, as service needs change over the course of treatment. Individualized treatment is offered depending on what stage of recovery a person is in. Examples of services include basic education about the illnesses, case management, help with housing, money management, relationships, and specialized counseling specifically designed for individuals with co-occurring disorders. This is a comprehensive and longterm approach to treatment that has hope and optimism as core beliefs. Services are offered in a positive and supportive atmosphere. Ultimately, the goal of integrated dual disorders treatment is to help people learn to manage both their mental illness and substance use problems so that they can pursue meaningful life goals. The Substance Abuse and Mental Health Services Administration (SAMHSA), and The National Institute of Mental Health (NIMH) offer the following set of evidence-based practices for adults with mental illness and co-occurring disorders. DBH endorses the Six Evidence Based Practices Tool Kits that are described below. In addition, Trauma Services is an evidence-based practice, important to the Division as it relates to the DBH Trauma Initiative and the importance of developing an All Hazards Disaster Plan. Further information is available at 1. Illness Management and Recovery - Wellness self-management encompasses a number of strategies designed to help consumers manage their symptoms. Psycho-education, social skills training, cognitive behavioral therapy, and coping skills training have been shown to help consumers manage their own mental health, reduce symptoms and relapses, and minimize the adverse effects of psychiatric illness on social and role functioning. 2. Medication Management The elements of an effective program to optimize the use of medications include: (1) a systematic evidence-based approach to medication selection and use; (2) measurement of treatment response and side effects; and (3) efforts to enhance patient adherence to taking prescribed medications. 3. Assertive Community Treatment (ACT), Intensive Case Management (ICM) Important features of ACT and Intensive case management include the following: a small caseload,

3 provision of services in consumers natural living settings, a 24-hour responsibility, and coordination of comprehensive multi-disciplinary services through regular treatment team meetings. 4. Family Psycho-education Effective family intervention programs provide a combination of education, problem solving, crisis intervention, and support. Family psycho-education has been shown to reduce relapse rates and facilitate recovery of persons who have mental illness and/or co-morbid disorders. 5. Supported Employment The supported employment model of vocational rehabilitation includes: rapid job searches and placement in competitive employment, on-going followalong supports after placement, integration of vocational and clinical services, and placing consumers in jobs that match their preferences. Supported employment approaches have been proven to help consumers secure and maintain meaningful jobs in the community. 6. Integrated Treatment for Co-Occurring Substance Use and Mental Health Disorders Substance use treatment that is integrated with mental health treatment and tailored for individuals with mental illness is more effective than separate substance use and mental health services. Effective models also integrate other services such as case management, medications, housing, vocational rehabilitation, and family intervention. 7. Trauma Services - There is a growing body of evidence that early intervention following traumatic incidents can avoid a variety of behavioral disorders. Effective treatment following traumatic events should include individualized counseling taking an historical account of both current and past trauma and providing psycho-educational information about trauma phenomenon. Effective treatment will include concurrent treatment of trauma issues and co-morbid issues including substance abuse when appropriate. Evidence Based Practices for Children and Adolescents One of the most comprehensive surveys of EBPs for youth with mental disorders are summarized by a literature search in the following journal article: Burns, B. J., Hoagwood, K., & Mrazek, P. J. (1999) Effective treatment for mental disorders in children and adolescents, Clinical Child and Family Psychology Review, 2(4), The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Technical Assistance Center for Child Health & Mental Health Policy support the following priority areas for evidence-based practice interventions for children and adolescents: 1. Evidence-Based Prescribing Practices A set of treatment guidelines for using antipsychotic medications with aggressive/assaultive children and adolescents with complex clinical issues in in-patient and day treatment settings. Training and supervision and a set of clinical protocols assist psychiatrists with using and implementing specific treatment using anti-psychotic medication for children and adolescents. 2. Family Education and Support Services - In family education and support services, parents are viewed as partners and the family is reinforced as the primary caregivers of children. This program enhances the ability of a family with a seriously emotionally disturbed child or adolescent to function as a family unit within the community. An array of flexible support

4 services is available to families such as support groups, in-home visits, individual and family advocacy, respite, telephone hotlines, transportation, and family recreation events. 3. Functional Family therapy (FFT) FFT is a family-based prevention and intervention program that combines and integrates the following elements into a clear and comprehensive multi-systemic clinical model: established clinical theory, empirically supported principles, and extensive clinical experience. Implementation of FFT in communities focuses on training to develop therapist competence rather than simply teaching skills. FFT utilizes a systematic model of intervention phases with specific goals catered to the unique characteristics of the family interaction, thereby maximizing treatment fidelity. 4. Home-Based Crisis Intervention (HBCI) HBCI provides in-home crisis services to families where a child is at imminent risk of psychiatric hospitalization or out-of-home placement. Linked to emergency rooms, these programs provide intensive in-home intervention for 4 to 6 weeks with the goals of admission diversion, teaching problem-solving skills to the family, and linking the child and family with community-based resources and supports. Caseloads are small (one counselor to two families) and access to a counselor is available 24 hours a day. 5. Home and Community-Based Services (HCBS) HCBS is a mechanism serving the specialized needs of families with children diagnosed with severe mental illness who are at risk of out-of-home placement. Wrap-around services include individualized care coordination, intensive in-home services, respite care, family support services, crisis response services, and skill-building services. 6. Intensive Case Management (ICM) ICM is designed to assist seriously emotionally disturbed youth and their families residing in the community, Intensive Case Managers work intensively with a child s family, and coordinate with teachers and other helping professionals to develop an individualized comprehensive service plan. Qualified and specially trained professionals assess and coordinate the supports and services necessary to help children and adolescents live successfully at home and in the community. Caseloads are small (one ICM to twelve recipients) and the intensity level of ICM for children and youth is demonstrated by the 24-hours a day, 7 days a week response capacity. 7. School-Based Mental Health Services School-based mental health services provide a variety of clinical and non-clinical services to children and families. Services include individual and group therapies for children and families, consultations to school staff and school committees or teams, intervention with children throughout the school day (crisis or planned), and medication reviews. Services are provided in the familiar and natural school setting during and after the regular school day. 8. Post Traumatic Stress Disorder (PTSD) Treatment PTSD treatment should encompass specialized mental health services for traumatized and bereaved children, adolescents, and their families. More specifically, research indicates the importance of trauma/grief-focused school-based and home-based assessment procedures and clinical interventions specific to children and adolescents exposed to traumatic events. Additionally, prevention and intervention for youth exposed to trauma may decrease the likelihood of developing persistent mood and/or conduct disorders.

5 Emerging Promising Practices Emerging Promising Practices are those practices for which the scientific evidence is building and which address a widely held client need or gap in our service system. Supported Housing, various approaches to treating trauma, and emerging treatment for FASD are examples of promising emerging practices. Additionally, there are a number of models of peer/family services that have been implemented nationally and for which there is ongoing research to validate their effectiveness. Alaska Values Based Practices Alaska Values Based Practices are those practices for which the research base is currently limited or inconclusive with regard to effectiveness but which are approaches that consumers/clients and families particularly request and find helpful. Examples include family-to-family education, rural family recovery camps and transitional residential services. Given that the research agenda is limited, there will always be good practices for which there is little available evidence of their effectiveness. The publicly funded behavioral health system should implement such practices and evaluate their effectiveness to add to the body of knowledge.

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